Md. Code Regs. 10.67.03.06

Current through Register Vol. 51, No. 11, May 31, 2024

Section 10.67.03.06 - Access and Capacity: Benefits and Appointments

An MCO applicant shall include in its application the following information or descriptions:

A. Written evidence of the applicant's preparedness to provide benefits equivalent to the benefit level mandated by the Maryland Medical Assistance Program as described in COMAR 10.67.67;

B. A description of any benefits the applicant proposes to provide in addition to those required by the Maryland Medicaid Managed Care Program, including:

(1) Whether there are any limitations on these services; and

(2) The name, medical specialty, location, and employment status as enumerated in Regulation .05F(5) of this chapter, of any providers rendering additional services;

C. A copy of the written procedures specifying how an enrollee may select and change primary care providers;

D. A written explanation of the applicant's plan to provide adequate case management and continuity of care, including its policies and procedures concerning:

(1) Case management;

(2) Making appointments;

(3) Appointment no-shows;

(4) Follow-up for appointment no-shows who are at-risk patients; and

(5) Referral claims and reimbursement for authorized noncontractual and out-of-plan provider services;

E. Documentation of the applicant's preparedness to collaborate with providers of self-referral services, and reimburse at the Department's established fee-for-service rate, for permissible self-referred services as defined in COMAR 10.67.67.28;

F. Documentation of the applicant's preparedness to provide the full range of EPSDT services;

G. Documentation of the applicant's preparedness to work with the Department's behavioral health ASO for coordination of somatic care, behavioral health care, and all appropriate drug utilization review.

H. A written explanation of the prospective MCO's plan for providing monthly updates to primary care providers of the enrollees assigned to them;

I. Documentation of the applicant's plan to satisfy statutory requirements that enrollees be notified of due dates for obtaining immunizations, examinations, and other wellness services;

J. Documentation of how the applicant will provide timely access to health care services, including but not limited to:

(1) Waiting time for telephone calls to be answered;

(2) Obtaining appointments; and

(3) Waiting times in practitioners' offices;

K. Documentation of access provisions to address the needs of enrollees who:

(1) Do not speak English;

(2) Are deaf; or

(3) Have one or more physical, mental, or developmental disabilities;

L. The applicant's proposed written utilization management program that specifies, at a minimum, policies and procedures for:

(1) Referral processes;

(2) Services requiring preauthorization, including mechanisms for ensuring consistent application and requesting provider consultation when appropriate;

(3) Criteria for determining medical necessity;

(4) Provider responsibilities for utilization management activities;

(5) Case management processes;

(6) Utilization tracking mechanisms and the determination of over-utilization and under-utilization of health care services;

(7) Integration of activities with quality improvement for provider profiling; and

(8) Appeals and grievance processes;

M. The applicant's proposal to establish and utilize a consumer advisory board, including:

(1) The anticipated composition of the board;

(2) Identifying staff responsible for serving board needs; and

(3) Proposed mechanisms by which the board will furnish the MCO with regular enrollee input;

N. A written description of the applicant's proposed member services unit, including a consumer services hotline, describing how the applicant will use this:

(1) As an information source for enrollees;

(2) To respond to enrollees' needs and requests in a timely manner; and

(3) To facilitate enrollees' access to needed health care services, including how the hotline will function as a point of entry for complaint resolution and internal grievance procedures;

O. A written Enrollee Outreach Plan that:

(1) Describes how the MCO intends to comply with the outreach, quality assurance, and provision of health care services requirements of Health-General Article, §15-103(b)(9), Annotated Code of Maryland; and

(2) To the extent that the materials are relevant to the requirements of §O(1) of this regulation, may incorporate by reference written materials provided by the applicant in response to other elements of its application; and

P. Documentation of any service the MCO elects not to provide, reimburse for, or provide coverage of, because of a moral or religious objection, which shall:

(1) Be provided to the Department whenever an MCO adopts the policy during the term of the contract;

(2) Be consistent with the provisions of 42 CFR § 438.10, as amended; and

(3) Be provided to enrollees within 90 days after adopting the policy with respect to any particular service.

Md. Code Regs. 10.67.03.06

Regulations .06 recodified from 10.09.64.06 effective 46:22 Md. R. 976, eff. 11/1/2019